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General NPI Number Information
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NPI Number | 1558508606
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Entity Type | Organization
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Legal Business Name | JEFFERSON PHYSICIAN NETWORK, LLC
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Dates
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Enumeration Date | 01/12/2009
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 1400 HIGHWAY 61 SUITE 240
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City | FESTUS
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State | MO
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Zip | 63028-4100
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Country | US
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Telephone | 636-931-4002
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 US HIGHWAY 61
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City | FESTUS
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State | MO
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Zip | 63028-4100
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | MR. DANIEL S. ECKENFELS
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Credential |
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Telephone | 636-933-1107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 2007029096
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License Number State | MO
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